Postpartum Assessment

The Psychological Component

Anna Hans, RN, MSN

The postpartum patient’s emotional status plays a significant part in her recovery and
her adjustment to her infant. Postpartum hospital stays are very brief, so nurses must
make every encounter with the patient meaningful. Developing a systematic method of
assessing the patient will save time and allow for quicker identification of patient needs.
Assessment guidelines that focus on three aspects of the patient’s psychological status
are provided 1) patient’s reaction to the birth experience, 2) patient’s adaptation to the
infant, and 3) family’s reaction to the infant.

The emotional state of a patient cannot be completely assessed in a short time, or

during a single interaction with the patient. The nurse can make an initial assessment
and then expand her findings during each subsequent interaction with the patient. Good
communication skills are essential in accomplishing this part of the assessment, as it
involves more than merely asking questions. The nurse must establish a rapport with
the patient if the nurse wants to help the patient verbalize feelings. Promoting trust
begins with the nurse’s first interaction with the patient. The nurse should greet the
patient by name and, in turn, tell the patient the nurse’s name. Once rapport has been
established, the nurse will have the advantage of being able to provide a therapeutic
milieu if and when the need arises.

Reaction to Birth Experience

According to Rubin, the postpartum patient goes through predictable restorative phases
as she integrates her new infant into her real situation: taking in, taking hold, and letting
go.1 The first of these phases, the taking-in phase, lasts from two to three days. During
this time, one of the patient’s first needs is that of a long restorative sleep. The patient
has expanded a great deal of energy during labor and the sooner she is able to obtain a
lengthy deep sleep the better able she will be to proceed with new tasks.

The patient will need several rest periods each day during the hospital stay. Increased
need for rest is sometimes interpreted negatively by nurses, especially in a situation
where the patient says, “I’m tired; do you think the nursery nurses would mind feeding
my baby next time?” The nurse can be instrumental in organizing routine nursing
activities so the patient will have minimal interruptions and, thus, obtain more rest.

Another patient need is that of food. Some people associate food with being mothered,
so food is very important in meeting the dependency needs of postpartum patients. The
postpartum patient may eat all the food that is brought to her on meal trays and then
ask family members to bring food from home. Hospitals that recognize this need for
increased food will have nutritious snacks available on the postpartum unit so that
nurses can offer the snacks to the patients.

During this taking-in phase, the mother is passive and dependent. She does what she is
told, does not initiate suggestions for her care or for contact with her infant, and is
perfectly happy to allow others to make decisions for her. The woman seems to need to
be nurtured. Nurturing or pampering the patient should assist her in moving on to the
more complex task of nurturing her infant. Nurses sometimes overlook this need for
nurturing because nurses are concerned about assisting patients to become
independent and, thereby, ready for discharge within 24-72 hours following delivery.

Patients are very talkative during the taking-in phase and need to relive their birth
experience. The patient may be talking on the telephone each time the nurse walks into
her room. At times, accomplishing all required nursing activities is difficult due to the
amount of time the patient is on the phone. Nurses must use kind firmness and inform
the patient of the essential activities that need to be accomplished.

Every patient should have the opportunity to describe her labor and delivery or
cesarean section in detail. Even though the patient talks to her friends and family about
her birth experience, the patient may find more meaning in discussing the experience
with the nurse who cared for the patient during labor. Realistically, this is not always
possible; therefore, the nurse on the postpartum unit should elicit this information from
the patient. A simple question (i.e., “What did you think of your labor?”) or a statement
(i.e., “Tell me about your labor experience.”) will usually lead the patient to give a
detailed description of her labor and delivery.

As the patient describes her experience, she sometimes has hazy or vague memories
of certain events. When this occurs, the nurse can assist the patient by obtaining
information to help clarify the situation. If this information is not available from the
patient’s chart, the postpartum nurse may have to consult with the nurse who was with
the patient during labor or with the patient’s physician.

The patient’s description of her labor usually provides the nurse with useful information
as to whether the patient’s expectations about labor were met. The patient who
describes her labor in an enthusiastic, animated way probably feels very positive about
her birth experience. This patient is more than likely to have increased self-esteem as a
result of this positive experience, and she will be

prepared to take on the parenting role.

The mother whose expectations were not met, or who was disappointed in how she
performed during labor, will need the nurse’s assistance in understanding the
experience and in working through her feelings. This patient will be experiencing a loss.
Thus, the nurse will need to assist the patient in working through her loss. One of the
first steps is assisting the patient to verbalize her feelings about the situation. Other
helpful interventions include providing explanations for events that were perhaps
misinterpreted by the patient and providing reassurance that her behavior is accepted
and, under the circumstances, very appropriate. The timing of the discussion of the birth
experience must be carefully planned. The nurse must have time to listen to the
patient’s response once she elicits the information.
The postpartum patient moves from being dependent to independent around the time
she is preparing to leave the hospital. In this second phase, the “taking-hold” phase, 1
the patient becomes independent, is concerned with bodily functions, makes decisions
about self-care, initiates infant caretaking tasks, has a heightened readiness for
learning, and plans for discharge.

Adaptation to Infant

One observation period with the mother and infant may not be sufficient to assess
adequately maternal-infant bonding, especially if the mother is fatigued or in pain during
that time. The nurse should make several observations. Does the mother hold the infant
facing her so that she has eye-to-eye contact with the infant? This is called the en face
position and is a very important natural response. 2

The nurse should also observe how the mother touches the infant. As she progresses
through the identifying phase of attachment, does the mother use a finger-tip touch,
followed by use of the palm of her hand, then the complete hand, and finally, enfold the
baby in a cuddle position?3., 4.

The mother needs to know that her infant is complete. If the patient has not unwrapped,
undressed, and examined her infant thoroughly, the nurse should encourage her to do
so. A statement such as “Let’s look at your baby together,” may be the invitation the
mother needs.

Comments that the mother makes about her infant can provide cues as to whether or
not her attachment to her infant is adaptive. The mother usually will identify features of
her infant as being like some family member; for example, “He has Daddy’s ears and
Mommy’s dark hair.” If the mother says something like “You were supposed to be a
boy,” this may indicate some disappointment in her infant’s sex. The nurse should
explore with the patient her feelings about having a girl versus a boy, and let her know
that it is okay to be disappointed regarding the infant’s gender.
The manner in which the mother responds to her infant’s behavior also should be
assessed. Does she cuddle the infant when he cries, or does she talk to him in a
soothing voice? Does the mother recognize the infant’s responses to her and does she,
in turn, respond appropriately? If the infant is hungry, does the mother willingly postpone
her own meal and feed the infant first?

Observing the mother when she is performing caretaking tasks, i.e., changing a diaper,
usually provides helpful information as to how comfortable the mother feels when
handling the infant and whether or not health teaching is needed. If the mother has not
had previous experience with an infant, she probably will need guided practice in such
tasks as changing diapers, cleansing the umbilical cord, dressing the infant, and other
general care activities.

Success in infant feeding is very important to the mother; therefore, the nurse should be
present during the first few feeding periods. If the infant is sleepy and does not nurse
well, or has a poor sucking reflex, the mother needs a supportive, reassuring person
present.

When assessing attachment behaviors, the nurse needs to be aware of cultural

influences so that she can avoid misinterpreting certain behaviors. Most of the studies
reported about attachment and most of the available tools regarding maternal behaviors
are based on women in contemporary Western society. Therefore, when dealing with
women from other cultures, the nurse must attempt to understand the values, beliefs,
and attitudes of the respective culture in relation to the childbearing experience.

Family’s Reaction to Infant

Family relationships are also important to assess. Observations should include how
significant family members are relating to the patient and to the infant. In a healthy
environment, family members usually share their ideas and feelings about their new
roles, i.e., making statements about how it feels to be a new father or a new
grandparent. Family members also share ideas about the method of infant feeding, the
type of diapers to use, and so forth.
Another observation to make is the mother’s reaction when family members are
present. Is the patient elated, withdrawn, or hostile in their presence? At times, family
members are so excited and attentive toward the new infant that the mother feels
neglected. She is no longer the focus of attention as she was during

pregnancy and childbirth; this sometimes can lead to feelings of neglect and
depression.

The nurse should observe how siblings interact with the infant. In many hospitals,
programs exist to allow sibling visitation privileges. This arrangement allows the nurse
to see the family interact and to observe cues that might indicate a problem in family
relationships. The nurse should take advantage of this opportunity and spend some
time in the patient’s room when the entire family is present.

The nurse should, at some time, discuss with the mother how she plans to prevent
problems with sibling competition. A nonthreatening strategy for assessing a mother’s
need in this area is by asking “what if” questions: “What would you do if (name of
sibling) hits the new baby with a toy?” or “What will you do if (name of sibling) cries
every time you nurse the baby?” The patient’s response to these questions will inform
the nurse as to whether the mother will be able to handle problems effectively with the
sibling. The responses also could alert the nurse to the need to provide the mother with
information regarding handling such problems.

Summary
Increasing health-care costs are sending patients home from the hospital earlier and
earlier, resulting in nurses having less time to assist postpartum mothers with their
recovery and assumption of new roles. A challenge for nurses working with families
during the postpartum period is to accomplish expected outcomes in a very short period
of time. The guidelines suggested in this article will aid nurses in doing effective
assessments so that patients will receive maximum benefits from brief hospital stays.